Video/audio available: UNMC chancellor, director of Pancreatic Cancer Center of Excellence, discuss the disease

Sunil Hingorani, MD, PhD

Sunil Hingorani, MD, PhD

In his latest “Health Care Heart to Heart” podcast, now streaming, UNMC Chancellor Jeffrey P. Gold, MD, speaks with Sunil Hingorani, MD, PhD, director of the Pancreatic Cancer Center of Excellence at the Fred & Pamela Buffett Cancer Center.

A Dropbox with video and audio clips of the two-part discussion is available for media use. Dr. Hingorani and other researchers and clinicians at the Pancreatic Cancer Center of Excellence also are available for interviews during November, which is Pancreatic Cancer Awareness Month, or on Nov. 16, which is World Pancreatic Cancer Day.

 Part 2 of Dr. Gold’s discussion with Dr. Hingorani will post the week of Nov. 13. Clips from that segment are available here and are not under embargo.

 The video clips and audio clips of Sunil Hingorani, MD, director, Pancreatic Cancer Center of Excellence, University of Nebraska Medical Center, include:

0:00: His personal story

This battle and this cancer is very personal for me and for my family, and that goes back to the time when I was just finishing my clinical training in oncology and my father was diagnosed with metastatic pancreas cancer and I had trained in gastrointestinal malignancies. I was actually doing research in a laboratory that studies the key mutation that drives pancreatic cancer, but this was the late 1990s, and frankly, we did not have any therapies essentially at all to even attempt to treat this disease. So it was an extraordinarily challenging, frustrating, and ultimately futile attempt to try to impact the disease significantly. A lot of being a good doctor and practicing the best medicine involves supportive care. So focusing on things like nutrition, pain management, hydration — that actually had a lot more to do with improving my father’s quality of life than any of the drugs, and we’ve tried to incorporate some of those lessons into what we’re doing now.

1:18:  A shared passion

I’m always happy to celebrate every additional life that we can save or that we can extend, but in the grand scheme of things, we have to do much, much better. This shared passion that we have for this disease and connection contributes to what I think is a really radically and new approach to how we study the disease, how we deliver care to our patients, and how we get the various stakeholders, the scientists, the clinicians, the support services to engage with each other and interact in a more formal and structured way from the beginning.

1:55: The difficulty of diagnosis

Pancreas cancer is the emperor of emperors. It is truly outsized in terms of its mortality, the rapidity with which it can lead to demise, the debilitating symptoms that are associated with it, and the difficulty in detecting it early, early enough to intervene, and its ability to resist just about every therapy. Pancreas cancer not only has no real localizing symptoms associated with it that can call attention to it. The symptoms it does create, when there are symptoms at all, actually lead you away from the diagnosis rather than towards it. So for example, because the pancreas is up against the spine deep in the body, patients will sometimes present with low back pain. Now, that is probably one of the most common maladies of anyone over the age of 40. In fact, I have low back pain right now. You certainly don’t want to automatically go to the diagnosis of pancreas cancer if someone’s having low back pain because it’s almost always musculoskeletal and therefore it often gets treated with anti-inflammatory medicines with ice, with physical therapy. And you lose a few months during that process before realizing that that’s really not what the cause is. Other times patients will have just a vague abdominal discomfort, which we almost always attribute to reflux, acid reflux.

3:22: A revolutionary approach

There’s truly been a revolution in how we think about how the tumor’s made up, how it’s constructed, and what aspects of it we want to try to attack, and what aspects we want to try to promote. For the first 150 years of engaging systematically with this cancer and being aware of it as a cancer with a label, we actually had most of that understanding upside-down. As just one example, pancreas cancers resist virtually every drug we throw at it, even when those drugs have worked in the laboratory killing cells as we grow them in a dish quite effectively for almost all the other solid tumors we have. That’s how we learn to come up with the regimens that we use in patients. It’s some subset of the drugs that worked in a laboratory setting that end up working in patients. Well, the one cancer for which that’s essentially been 0% success is pancreas cancer. So there’s a paradox here, and what we’ve come to realize is the first mechanism of resistance is that those drugs never got into the tumor. They never penetrated the very dense cement-like matrix or fortress, if you will, that the tumor constructs around itself, a fortress that we thought was the body’s response to try to contain the cancer, and we now understand is actually being orchestrated by the cancer cell to shield itself and protect itself from the therapies we might try to treat it with.

4:59: New targets

The lessons that we have learned are important for a number of reasons. They change the way we completely conceptualize this cancer, think about how it’s constructed, and they give us an entirely new set of targets, therefore, to go after things that we didn’t realize we needed to be going after.

5:20: Making inroads

We are in a completely different era now than we were even 10, 12, 15 years ago. And so the reputation that this cancer has deservedly earned over many decades is perhaps no longer fully appropriate. We are now increasingly seeing more and more cases of very long-term survival and even some cures for a cancer that notoriously was impossible to achieve. Moreover, the explanations we have now for why our previous strategies failed are so simple, so straightforward, and so powerful that by simply flipping the switch on our approach, we are beginning to make inroads again in a way that we hadn’t seen before.

6:13: Hope

The most important tool, the most important weapon that a patient arrives with is what I want to try to always promote and sustain and increase. And that’s hope. What I would say to any patient is, first of all, don’t believe what you read on the internet. A lot of it is doom and gloom and it doesn’t have the context, but most importantly, you are not alone. There are things that can be done, especially at specialty centers that bring a dedicated and concerted interdisciplinary team to treat the problem because of the spirit of collaboration and collegiality. Each of the doctors here in surgery, in oncology, in radiation therapy, in nutrition, in genetics, in pain management and more, were willing to completely change their clinic schedules so that they could all congregate together, 40-plus people on a given afternoon, be present in the room simultaneously while patients are actually waiting in their clinic rooms, and together as a team, we review each patient’s data, and we come up with the best care plan that we can conceive. And I can tell you the comprehensive care plan that emerges when you have all of your colleagues in the room together at one time is very different than when each one of those specialists tries to come up with a plan in isolation. And that effort and that ability to create this kind of approach to a patient is truly unique in the country, and I believe transforms the quality of care that they get.

8:02: Clinical trials

It’s incumbent upon us to create not only the most novel and cutting-edge clinical trials, but also to find the appropriate trial for each patient, to think of each patient as an individual entity and not a statistic. There’s a reason that I never quote statistics when I’m in the clinic. I use them all the time in my laboratory research, because it becomes essential. And in the laboratory, I might be studying a million cells or a billion cells, and so we’re obligated to count them and to try to use statistics to understand the result.

8:37: Ignoring the statistics

When I’m in the room with a patient, I’m dealing with one person, and for them, whatever we come up with is either going to be 100% or 0%. So I start out by taking all the statistics and throwing them out the window, and then you examine the person in front of you. You look at them as a human being.

9:00: The high-risk clinic

One of the really fantastic programs that’s been longstanding here, and it’s wonderful both for the patients but also for the national and international effort to develop early detection markers, is this high-risk clinic. If you have a one first-degree relative or two first-degree relatives or three, the risk of pancreas cancer actually increases exponentially. What we want to do for those people and those families is create a surveillance program. We meet with them every six months. We do a physical exam, we take a detailed history, and if there’s anything that seems slightly off, we will do a CAT scan or an endoscopic study at a much earlier time point than we might otherwise. And we also draw blood samples. Now, here’s the beauty of that study. A small subset of those patients, inevitably will develop pancreas cancer. And on those patients first, we will likely have caught it earlier because we’ve been following them so closely. But we’ll also have their blood samples from one year before the diagnosis and two years and five years. Now we can go back to those blood samples and ask what’s different there. That’s where we’re going to find the marker because we’ve enriched for, we’ve selected for the patients that are most likely to have those markers.